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PPM <3 > clinical interview > Flashcards

clinical interview Flashcards

1
Q

How are clinical interviews used in psychological investigations?

A

Another form of test used in psychiatry (less so in psychology) is clinical interviews and also get a score for diagnosis.

Clinical interviews are not completely subjective. Questions are asked which map on to a specific diagnosis. We can also do single case studies when you find someone with a conditions and describe it in detail - especially done when the field/condition is new.

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2
Q

What are the demographics of a psychological history?

A
  • Name
  • Age
  • Gender
  • Employment
  • Relationship status
  • Children
  • [Summary of diagnoses]
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3
Q

What are the presenting circumstances of a psychological history?

A
  • Circumstances of presentation
  • Context of presentation
  • Timeline of problems
  • Precipitating events
  • Perception of problems
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4
Q

Under what circumstances could someone come to a psychiatrist?

A
  • under a section 136 - when someone is brought in from the public place by a police officer for example, someone who was acting in a manner suggesting they may be suffering from a mental disorder and in need of care and control
    • Referred by their GP
    • Present to A+E in crisis with suicidal feelings or following self harm or suicide attempts
    • Referral from other specialists

Timeline of problems can be years apart.

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5
Q

What are the essential areas of affective symptoms on a psychological history?

A
  • core symptoms
  • somatic
  • psychology
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6
Q

What are the core symptoms in history taking?

A
  • Low mood - feeling unhappy, sad, down.
  • Poor energy/fatigue
  • Anhedonia - inability to feel pleasure
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7
Q

What are the somatic symptoms in a psychological history?

A
  • Poor appetite (or increased)
  • Weight loss (or increased)
  • Insomnia (or hypersomnia) - typically wake up tired, unrefreshed, but unable to return to sleep
  • Loss of libido - women is mainly loss of interest, in men sexual dysfunction can be caused by depression or by antidepressants, but in general the effect on libido of depression is mainly loss of interest rather than erectile dysfunction/vaginal dryness.
  • Poor concentration/short-term memory
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8
Q

What are the psychological symptoms in a psychological history?

A
  • Helplessness
  • Hopelessness
  • Worthlessness
  • Guilt
  • Suicidal thoughts - have to ask about it. Direct approach often appreciated by patients, talking about it openly rather than making it a taboo subject to encourage people to give honest answers.
  • [psychotic]
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9
Q

How can we split symptoms?

A

Can split symptoms into affective and psychotic. Always want to ask about related symptoms, not just the initially obvious ones.

Affective means to do with mood - affect is like saying the weather specifically today, but mood is saying that it is January so what it is like normally (in context)

A normal mood should fluctuate throughout the day/week and with events.

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10
Q

What is needed to diagnose depression?

A

For depression has to be consistent low mood, most of the day, most of the days, for two weeks or more. Typically lowest in the mornings and evenings, more severe more the time.

By ICD-10 need 2 core and 2 associated for mild depression.

Moderate: 2 core and 4 associated

Severe: 3 core and 6 associated

Psychotic: must be severe + psychosis

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11
Q

What needs to be asked about suicide in a history?

A
  • Nature and duration of any suicidal thoughts
  • Intent
  • Plans
  • Previous suicidal behaviour
  • Deliberate self harm

Intent - many people have suicidal fantasies but wouldn’t ever act on it

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12
Q

What is asked about psychosis in history taking?

A
  • Open questioning - have you had any other unusual experiences recently, like seeing or hearing things that other people cant that shouldn’t be there. Any other worries that we haven’t talked about, like people trying to harm you or send you special messages?
  • Delusions
  • Hallucinations
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13
Q

What other areas are asked about in a history?

A
  • Anxiety - becomes pathological when it is of frequency or intensity that it interferes with your ability to function (socially, occupationally, etc)
  • Gender identity
  • ADHD - hyperactivity symptoms and inattention symptoms
  • Eating disorders
  • Paraphilias - a condition characterized by abnormal sexual desires, typically involving extreme or dangerous activities
  • PTSD
  • Memory
  • Substance use
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14
Q

Past psychiatric history

A
  • Previous diagnoses
  • Previous hospitalisations
  • Previous treatments
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15
Q

Past medical history

A
  • Comorbid medical problems
  • Particularly metabolic disorders
  • Recent blood tests
  • Head injuries/CNS surgery
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16
Q

Social history

A
  • Current home circumstances
  • People at home, relations and ages
  • PoC - package of care
  • Employment/income
  • Financial situation
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17
Q

Family history

A
  • history of illnesses in family

- include relation and age

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18
Q

Drug history

A
  • psychoactive medication
  • others
  • allergies
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19
Q

Substance history

A
  • alcohol
  • tobacco
  • recreational drugs
  • OTC
  • herbal treatments
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20
Q

Personal history

A
  • life story!
  • psychosexual history - current relationships, first relationship, pattern of relationships, gender preferences, previous marriages, etc
21
Q

Mental state examination

A
  • Appearance
  • Behaviour
  • Speech
  • Mood
  • Thought
  • Perception
  • Cognition
  • Insight
22
Q

About appearance in the mental state examination

A
  • Dress
  • Self-care
  • Age
  • Ethnicity
  • Gender

Tells you a bit about how long the problems may have been there for.

Manic can also be seen through dress - bright colours etc

23
Q

About behaviour in the mental stat examination

A
  • Appropriateness of behaviour
  • Eye contact
  • Rapport
  • Engagement
  • Any particular abnormal movements, stereotyped movements, mannerisms, tics etc
24
Q

About speech in the mental state examination

A
  • Rate
  • Rhythm
  • Tone
  • Volume
  • [content] - eg frequent swearing
  • Other abnormalities
25
Q

About mood in the mental state examination

A
  • Subjective - how they describe their mood
  • Objective - how we objectively assess someone’s mood
  • Affect - reactive affect, depending on what you’re talking about how they react
26
Q

About thought in the mental state examination

A
  • form
  • content
  • remember suicide!
27
Q

About perception in the mental state examination

A
  • Hallucinations
  • Other abnormalities of perception
  • Reported or apparent from observation
28
Q

About cognition in the mental state examination

A
  • Not always needed to formally assess
  • [Orientation]
  • Other formalised
  • AMTS
  • MMSE
  • ACE
29
Q

About insight in the mental state examination

A
  • Insight into condition
  • Extent of condition
  • Attribution of symptoms
30
Q

What is diagnosis?

A

The identification of the nature of an illness or other problem by examination of the symptoms.

DIFFERENTIAL DIAGNOSIS: a possible list of diagnoses pertaining to a specific symptom/set of symptoms

DIAGNOSTIC CRITERIA: a list of criteria or algorithm required to demonstrate a specific diagnosis

31
Q

Why do we need diagnosis?

A
  • To enable following treatment protocol and rehabilitation strategies including national guidelines eg NICE guidelines
  • To enable patient education
  • To access services
  • To aid in focusing research questions

To be able to pertain to treatment protocol, patient education so they can look up what they have and come back with questions, research

32
Q

How do we go about making a diagnosis?

A 
• Shortness of breath: differential diagnosis:
	- Asthma
	- COPD
	- Pneumonia
	- PE
	- Pneumothorax
	- Malignancy
	- Interstitial lung disease
	- Pulmonary oedema
• Patient history
• Examination
• Investigations
	- Peak flow
	- Lung function tests
	- ABG
	- Chest x-ray
	- Chest CT
	- VQ scan
	- Bronchoscopy
	- Lung biopsy
33
Q

Making a psychiatric diagnosis…

A 
• History
• Mental state examination
• Physical examination
• Investigations
	- Blood tests
	- Imaging
	- Psychological questionnaires
	- Other investigations eg EEG, LP
• Collateral history, MDT input
• Longitudinal documentation
34
Q

What is meant by the mental state examination providing longitudinal documentation?

A

Provides longitudinal documentation, like a photograph which can be lined up to see if the patient is getting better or worse. Only thi

35
Q

What are the possible differential diagnoses in psychiatry e.g. from hearing voices?

A
  • Side effects of L-Dopa
  • Psychosis associated with tumour
  • Psychosis associated with infection (eg HIV)
  • Psychosis associated with autoimmune disease
  • Drug-induced psychosis (substances)
  • Schizophrenia
  • Mania
  • Psychotic depression
  • Post-partum psychosis
  • Emotionally Unstable Borderline Personality disorder
36
Q

How can we cut down the differential diagnosis of hearing voices with investigations?

A
  • Side effects of L-Dopa - medication review
  • Psychosis associated with tumour - CT/MRI head
  • Psychosis associated with infection (eg HIV) - blood test, CSF test
  • Psychosis associated with autoimmune disease - blood test
  • Drug-induced psychosis (substances) - urine drug screen
  • Schizophrenia
  • Mania
  • Psychotic depression
  • Post-partum psychosis - has the patient given brith recently?
  • Emotionally Unstable Borderline Personality disorder

We don’t do all of these tests on everyone - needs to be some kind of indication

37
Q

What are the different methods of diagnosis?

A

ICD 10
DSM V
Formulation

38
Q

About ICD 10 diagnosis

A

• 10th revision of the international statistical classification of diseases and related health problems listed by WHO
• >14,400 codes for symptoms, disease, social circumstances
• Work on ICD-10 began in 1983, completed in 1992, though it is now on it’s 5th edition
• Awaiting ICD-11…
• Used in 27 countries for resource allocation in healthcare
• 110 countries use it for statistical purposes
• Notable change/inclusion:
- Homosexuality removed from ICD-10 after 1992
- Gender identity disorder - F64.0
- Fetishism still in the ICD-10 (F65) (F56.1: transvestitism, F65.51: masochism, F65.52: sadism)

39
Q

About DSM V diagnosis

A
  • Diagnostic and statistical manual of mental disorders
  • Published by American Psychiatric Association
  • Classification of mental disorders based on standard criteria
  • DSM V - 2013
  • Used in the US
  • On-going issues around credibility, possible cultural bias - in 1973 5854 for removing homosexuality vs 3810 against!
40
Q

What is Axis I of DSM V diagnosis?

A

Principle disorder that needs immediate attention e.g. major depressive episode, acute psychotic episode in schizophrenia

41
Q

What is Axis II of DSM V diagnosis?

A

Personality disorders; developmental disorders, learning disability that may shape Axis I

42
Q

What is Axis III of DSM V diagnosis?

A

Medical or neurological problems relevant to psychiatric history e.g. asthma may be confused with acute panic attacks

43
Q

What is Axis IV of DSM V diagnosis?

A

Major psychosocial stressors e.g. family bereavement, divorce, loss of employment

44
Q

Wha tis Axis V of DSM V diagnosis?

A

level of function; global assessment of function, out of 100

45
Q

What is the GAF scale

A

move up the scale with better levels of functioning - 0-100

46
Q

What is formulation?

A

combination of predisposing, precipitating and perpetuating self, family and environmental factors

Formulation is the process of making sense of a person’s difficulties in the context of their relationships, social circumstances, life events, and the sense that they have made of them. It is a bit like a personal story or narrative that a psychologist or other professional draws up with an individual and, in some cases, their family and carers.

47
Q

When does something become a psychiatric disease?

A

Disease:

i. Discovered the causes
ii. Understood the pathogenesis
iii. Comprehensively described the clinical picture and the reaction to treatment
iv. Measured the natural history

None of the illnesses with which psychiatrists deal satisfies these criteria –> would it then become neurology

48
Q

What are the positives to diagnosis?

A
  • Education and health care plan (EHCP)
  • Social care package
  • Access to community activities
  • DLA
  • Freedom pass
  • Free prescription
  • Housing aid
  • Help with CV/job-seeking

Means that the patient gets access to these things. EHCP - teaching assistant for example.

49
Q

What is behavioural consistency?

A

Eg dress code (a casual dress sense causes people to take a person less seriously and less professionally).

Characteristics within behavioural consistency can reflect character or context, and we should ask which of these is more likely to determine the factor, such as dress sense. We ask ourselves this both consciously and subconsciously.

Dress code is mostly due to the context of the situation. It is hard for us to believe that this is the case for many factors because it means we aren’t in charge of the way we are - it is due to something external.

Science wants to predict, and so do humans. People acting dependently on context makes prediction hard as people may change depending on the environment.

PPM <3 (25 decks)

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